On the campaign trail, Donald Trump made many promises he doubtless won’t keep and a few he apparently doesn’t remember. But his nomination of Representative Tom Price, a hard-core conservative from Georgia, to be Secretary of Health and Human Services is a sign that repealing Obamacare is one promise he’d like to carry out. In every Congress since the Affordable Care Act was passed, Price has sponsored a bill to replace it. And there’s something else that should worry supporters of Obamacare: he’s a doctor.
To be fair, that makes Price more qualified than most of Trump’s Cabinet picks. But doctors have a history of opposing health-care reform of all kinds. The most famous instance is the American Medical Association’s campaign against the creation of Medicare. (In 1961, it hired an actor named Ronald Reagan to warn of the dangers of socialized medicine.) But the pattern emerged much earlier. In 1917, during the First World War, Californians voted on whether to institute universal health insurance. As Paul Starr recounts in “The Social Transformation of American Medicine,” a doctors’ group called the League for the Conservation of Public Health denounced the idea as a “dangerous device” imported from Germany and helped defeat the initiative. New Dealers pushed for Social Security to include health insurance, but public attacks by the A.M.A. convinced Franklin Roosevelt to steer clear, in order to save the rest of the bill. When Harry Truman proposed a universal-insurance plan, after the 1948 election, the A.M.A. put an end to it with the most expensive lobbying campaign that America had seen. And it helped derail Bill Clinton’s health-care plan, too.
It’s not only government reforms that doctors have resisted; it’s almost any plan that has threatened to reduce their income or autonomy. In the thirties, there were experiments with “pre-paid medical groups,” in which customers paid a flat fee to a set of doctors in exchange for care. The A.M.A. did its best to drive these groups out of business—it was fined for antitrust violations—and state medical societies ostracized doctors who joined up. The A.M.A. did tentatively endorse Obamacare, in a break with tradition, but only after helping nix the so-called public option. Since then, doctors have been among the program’s loudest critics.
Doctors have typically framed their opposition to reform in terms of the need to protect the doctor-patient relationship from outside interference. That’s understandable and legitimate. But many doctors have also fought reform because it runs counter to their financial interests. As an A.M.A report once said, doctors “display a consistent preoccupation with their economic insecurity”; more bluntly, “They think about money a lot.”
There’s plenty of evidence that financial considerations affect medical decisions: for instance, studies show that doctors who have a financial stake in imaging equipment like MRI machines order many more unnecessary MRIs. So it’s no surprise that the medical establishment’s criticism of reforms often hinges on money. The 1917 California insurance plan was attacked for offering treatment “at bargain counter prices.” The pre-paid medical groups were competition for traditional fee-for-service doctors. Doctors opposed universal health insurance in part because they feared that government involvement would drive down fees, and they tried to stop Medicare for the same reason. (They needn’t have worried: doctors’ incomes rose steadily in the years after Medicare was enacted, because they added more patients without having to cut their fees.)
Doctors, then, have behaved like a classic political interest group, and they’ve been very successful. They are now more likely to be in the top one per cent of earners than members of any other industry. They don’t have things all their own way—there are more administrative burdens, and insurance companies and the government are more intrusive than before—but the profession has been the single biggest beneficiary of the boom in medical spending in the past four decades, and doctors’ incomes have remained relatively untouched by attempts to rein in health-care costs.
There’s nothing inherently wrong with this; it’s how interest-group politics work. But what’s fascinating is that doctors are a powerful lobby in part because voters think of them as above the fray. Doctor regularly ranks as one of the three most trusted professions. People love their doctors and respect their expertise and work ethic. So it’s easier for politicians to go after reliable villains like insurance companies and drug companies. Suggesting that doctors might not always be disinterested policy advocates is a losing tactic.
We can expect to hear Tom Price invoke his medical background as he tries to roll back Obamacare. (He’s an orthopedic surgeon—according to one study, the most politically conservative field in medicine.) But let’s hope that doctors’ groups think twice before going along with him. Those groups have said that they support expanding access to medical care and giving people with preëxisting conditions affordable options, and doctors’ valid complaints about aspects of Obamacare are a reason to reform the program, not abandon it. After decades of using their political leverage to kill reform, it might be time for doctors to use that power to keep it alive. ♦